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Understanding the Terms of Dental Insurance

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One of the difficulties in dealing with dental insurance is that the terminology is quite different than anything you might encounter elsewhere, unless you work in the healthcare field. Whether you are comparing dental plans or trying to assess how your new plan works, understanding the language of dental insurance can be invaluable.

Class of service.  Service refers to what type of procedure or examination you are having performed by your dentist. Everything from fillings to root canals are placed in three or four classes by your insurance company. Where that particular service falls determines how your claim will be paid. For example, preventive services like a yearly or twice-yearly exam are put into the least restrictive category – Class 1 – and they are usually paid in full or 100 percent. But basic restorative care, such as a normal filling, goes to Class 2 and is paid at 80 percent. Class 3 is generally for major restorative care like crowns and bridges, and the insurer pays at 50 percent.

Co-insurance and co-payments. Easy to confuse, these terms describe separate costs you will pay when you see the dentist. Co-insurance refers to the amount of the bill you pay after the insurance company has paid its portion. Referring back to the class of service, if you had a cavity filled – a Class 2 procedure – the co-insurance rate would be 20 percent. Co-payments, on the other hand, are the amount that you pay when you see the dentist. Not every plan includes co-payments, but if so, it will be listed prominently in your class.

Out of network. The network for any insurer includes all of the healthcare providers that have agreed to accept insurance from that company. What happens if your dentist is not a part of your insurance company’s network? You can still file claims from that dentist, but the cost will be significantly higher than for a dentist who is in the network. If you already have a dentist you may want to determine what insurance providers he or she accepts. If you don’t yet have a dentist, it makes financial sense to get the list of dentists from your insurance provider and choose one you may have heard about or one that is convenient to your home or office.

Preventive care. This generally includes at least one visit to have your teeth cleaned every year and perhaps every six months. Preventive care is the best kind, from a financial standpoint, because it is nearly always covered at 100 percent. One X-ray a year and a fluoride cleaning may also be included. When choosing a new dentist, you should ask what preventive care is offered.

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